Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care and Food Service
Penalty
Summary
Staff failed to utilize Enhanced Barrier Precautions (EBP) and proper hand hygiene during direct care of a resident with a Stage 3 pressure injury. Certified Nurse Aides (CNAs) provided peri-care to the resident without donning gowns, as required by EBP protocols, and only wore gloves. During the care process, one CNA changed gloves without performing hand hygiene, and both CNAs assisted the resident's roommate with peri-care immediately after, again without performing hand hygiene between residents. After completing care, the CNAs removed their gloves but did not perform hand hygiene before exiting the room. One CNA then handled a mechanical lift, entered another resident's room, and performed tasks without hand hygiene, only sanitizing hands after returning the lift to storage. The mechanical lift was not cleaned before being placed in the common storage area. Additionally, multiple staff members, including Certified Medication Aides and CNAs, delivered food to residents in the dining room with their thumbs touching the eating surface of the plates, contrary to infection control expectations. Interviews with staff and review of facility policies confirmed that staff were expected to use proper PPE, perform hand hygiene before and after resident contact, and sanitize shared equipment between uses. The facility's policies also required the use of utensils, not bare hands, when serving food.